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PCM2 > Physical Exam Write-up (Normal Findings) > Flashcards

Physical Exam Write-up (Normal Findings) Flashcards

1
Q

What are the general components of the physical exam write-up with all normal findings?

A
  1. General Appearance
  2. Vitals
  3. HEENT
  4. Neck
  5. Breasts
  6. Thorax and Back
  7. Lungs
  8. Heart
  9. Abdomen
  10. Extremities
  11. Lymph nodes
  12. Neurologic
    (13. Gynecologic)
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2
Q

What are the components of the general appearance write-up?

A
  1. Age
  2. Gender
  3. Mental status (awake and alert)
  4. Appearance (healthy, looks stated age)
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3
Q

What are the components of the vitals write-up?

A
  1. Temperature (# degrees + method - oral, rectal, etc.)
  2. Blood pressure (Arm/Method)
  3. Heart rate
  4. Respiration rate
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4
Q

What are the broad components of the HEENT write-up?

A
  1. Head
  2. Eyes
  3. Ears
  4. Nose
  5. Throat and Mouth
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5
Q

What are the components of the Head write-up?

A
  1. Configuration (normocephalic)
  2. Hair (normal texture)
  3. Scalp (no lesions, tenderness)
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6
Q

What are the components of the Eye write-up?

A
  1. Sclera (white)
  2. Conjunctiva (pink)
  3. Fundoscopy:
    a. Red reflex (present)
    b. Disc (round, sharp margins, normal color)
    c. Vessels (normal caliber, A/V ratio ~1/2)
    d. Background (no abnormal pigmentation, hemorrhage, or exudate)
    e. Macular (visualized)
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7
Q

What are the components of the Ear write-up?

A
  1. External ear (no lesions, masses, tenderness)
  2. Auditory canal (nomral)
  3. Eardrum (tympanic membrane is gray, translucent, with a normal light reflex)
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8
Q

What are the components of the Nose write-up?

A
  1. Color (pink, no discharge)
  2. Septum (midline)
  3. Inferior and middle turbinates (normal)
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9
Q

What are the components of the Throat and Mouth write-up?

A
  1. Teeth (present and in good dentition)
  2. Tongue (no lesions)
  3. Gums and mucosa (no swelling, bleeding, infection)
  4. Pharynx and tonsillar fossa (normal)
  5. Opening’s of Stensen’s and Wharton’s ducts (identified)
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10
Q

What are the components of the Neck write-up?

A
  1. Active ROM (normal flexion, extension, lateral rotations, tilting)
  2. Trachea (midline, mobile)
  3. Thyroid (non-palpable or palpable, normal size and consistency, no lesions)
  4. Suprasternal notch (no pulsation)
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11
Q

What are the components of the Breast write-up?

A
  1. Inspection (normal size, symmetrical, nipples are symmetircal and everted)
  2. Palpation (no masses, no nipple discharge)
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12
Q

What are the components of the Thorax and Back write-up?

A
  1. Observation (symmetrical expansion with respiration)

2. Percussion (no spinal or CVA tenderness)

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13
Q

What are the components of the Lung write-up?

A
  1. Percussion and palpation of lung fields: (normal resonance to percussion)
  2. Auscultation (clear, normal vesicular breath sounds)
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14
Q

What are the broad components of the Heart write-up?

A
  1. Neck Veins (no JVD at 45 degrees)
  2. Carotid Arteries
  3. Precordium
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15
Q

What are the components of the Carotid Artery write-up?

A
  1. Palpation (normal upstroke and amplitude bilaterally)

2. Auscultation (no bruits)

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16
Q

What are the components of the Precordium write-up?

A
  1. Inspection (no lifts or heaves, PMI not visible)
  2. Palpation (no parasternal impulses, no thrills, PMI palpable in 5th ICS, MCL, normal size)
  3. Auscultation:
    a. S1 (heard best at apex, normal intensity)
    b. S2 (heard best at base, normal splitting, A2 > P2)
    c. Extra sounds (no S3, S4)
    d. Murmurs (no murmurs)
17
Q

What are the broad components of the Abdomen exam?

A
  1. Observation (scaphoid, no scars or striae)
  2. Auscultation (normal bowel sounds, no bruits)
  3. Palpation (no tenderness, masses, guarding - superficial and deep)
  4. Liver
  5. Spleen (non-palpable)
  6. Kidneys (non-palpable)
  7. Femoral pulses
18
Q

What are the components of the Liver write-up?

A
  1. Palpation (liver edge not palpable)

2. Percussion (~10 cm in R midclavicular line)

19
Q

What are the components of the Femoral Pulses write-up?

A
  1. Palpation (2+, normal and symmetric)

2. Auscultation (no bruits)

20
Q

What are the components of the Upper Extremities write-up?

A
  1. Nails (no cyanosis, clubbing)
  2. Palms (normal color, texture)
  3. Muscles (normal size)
  4. Joints:
    a. Interphalangeal (normal ROM, no deformities)
    b. Wrists
    c. Elbows
    d. Radial pulse (2+, normal and symmetric)
21
Q

What are the components of the Lower Extremities write-up?

A
  1. Nails (no cyanosis, clubbing)
  2. Muscles (normal size)
  3. Joints:
    a. Ankle
    b. Knee
    c. Hip
  4. Pulses
    a. Posterior tibial (2+ bilateral equal)
    b. Dorsalis pedis (2+ bilateral equal)
22
Q

What are the components of the Skin write-up?

A

Normal, no lesions

23
Q

What are the components of the Lymph Nodes write-up?

A
  1. Neck:
    a. Submental
    b. Submandibular
    c. Anterior and Posterior Cervical
    d. Pre and Post Auricular
    e. Suboccipital
    f. Supraclavicular
  2. Axillary
    a. Central axillary
    b. Pectoral
    c. Subscapular
    d. Lateral axillary
  3. Epitrochlear
  4. Superficial inguinal (horizontal and vertical)

All not palpable

24
Q

What are the broad components of the Neurologic write-up?

A
  1. Mental status (awake and alert, oriented to person, place, and time)
  2. Cranial Nerves
  3. Motor system
  4. Sensory
  5. Reflexes
  6. Coordination
25
Q

What are the components of the CN write-up?

A

II: Visual acuity - 20/20 with pocket screener, both eyes
Visual fields - intact in all fields

II and III: pupillary reaction light - direct and consensual normal, accommodation - normal (PERRLA - pupils, equal, round, reactive to light, accommodation for both)

III, IV, VI: EOM - intact
V: light touch face- normal in all three divisions of V
VII: wrinkle forehead, close eyes, show teeth (normal)
VIII: hearing - normal by rough testing
X: couch - normal
XI: shrug shoulders and check SCM - normal
XII: protrude tongue - midline protrusion

26
Q

What are the components of the motor system write-up?

A
  1. Normal tone

2. 5/5 strength in all extremities

27
Q

What are the components of the sensory system write-up?

A
  1. Light touch - normal
  2. Position sense - normal
  3. Vibration - normal
  4. Sharp - normal
28
Q

What are the components of the reflex write-up?

A
  1. Biceps (C5-6) 2/4
  2. Triceps (C6-7) 2/4
  3. Brachioradialis 2/4
  4. Knee (L2-4) 2/4
  5. Ankle (S1) 2/4
  6. Pathological - plantar reflex - none (bilateral)
29
Q

What are the components of the coordination write-up?

A
  1. Gait and balance - normal
  2. Finger to nose - normal
  3. Rapid finger movements - normal
  4. Tandem walking - normal
  5. Rombert - negative
30
Q

What’s on the differential for palpitations?

A

Cardiac

  1. Heart attack
  2. Arrhythmia (HOCM, heart disease)
  3. Valvular regurgitation
  4. Myo-/pericarditis
  5. Exercise-associated
  6. Anemia

Endocrine

  1. Thyrotoxicosis
  2. Electrolyte abnormalities

Psychiatric
1. Anxiety/panic attack

Other

  1. Medications
  2. Illicit drugs
  3. Nicotine
  4. Caffeine
  5. Musculoskeletal
  6. GERD

PCM2 (16 decks)

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